Provider Demographics
NPI:1124372719
Name:BAGNIEFSKI, LISA LYNN (RPH)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LYNN
Last Name:BAGNIEFSKI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-5427
Mailing Address - Country:US
Mailing Address - Phone:608-362-6300
Mailing Address - Fax:068-362-2744
Practice Address - Street 1:1006 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-5427
Practice Address - Country:US
Practice Address - Phone:608-362-6300
Practice Address - Fax:068-362-2744
Is Sole Proprietor?:No
Enumeration Date:2012-11-03
Last Update Date:2012-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12755183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist